Child Information Form - Happy Couples Healthy Communities

Child Information Form

Name*
First Last
Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Age
Date of Birth*
MM slash DD slash YYYY
Soc. Sec. #
Gender
Mother's Name
First Last
Mother's Age
Mother's Date of Birth
MM slash DD slash YYYY
Mother's Address (if different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mother's Home Phone
Mother's Cell Phone
Work Phone
Mother's Email
Mother's Occupation:
Father's Name
First Last
Father's Age
Father's Date of Birth
MM slash DD slash YYYY
Father's Address (if different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Father's Home Phone
Father's Cell Phone
Father's Work Phone
Employed by:
Parents Marital Status:
What would you like to accomplish from your time in therapy?
Signature
Consent to Treatment/Agreement to Pay I do hereby consent to treatment with Michael J. Brown, MSC, LMFT. I have not been given any guarantees in regard to treatment. I may terminate my treatment at any time, but I will still be responsible for payment for services received.
Client's or Authorized Person's Signature
I agree to pay Michael J. Brown for all services rendered at the time services are provided. I agree to a 48-hour cancellation notice or I will be charged for a missed appointment.